Despite death threats from rebel Chechens and Russian forces, Dr Khassan Baiev saved and treated countless lives from both sides of the Chechen wars. He did not waver from what he considered was his ethical duty as a doctor, and yet he was targeted and punished for his actions. 

His story, and the stories of many other heroic healthcare workers, who continued to provide care despite the dangers they faced during conflicts, are brought to life in Leonard Rubenstein’s new book, Perilous Medicine: The Struggle to Protect Care from the Violence of War. 

While there has been increasing discussion regarding the problem of violence against healthcare workers, such conversations often do not include the voices of healthcare workers themselves. 

Rubenstein and other global health experts reflected on the need to humanize these experiences of health workers during a Global Health Centre’s (GHC) launch of Perilous Medicine, and also considered long-term solutions to an increasing trend of attacks against the health sector. 

“Right now we’re in a situation where the violence continues. There’s been international paralysis, and we need to find ways to assess what is an extremely serious problem,” said Rubenstein, a professor at Johns Hopkins University.

In addition to extensive research, first-hand experience, and compelling personal stories, Perilous Medicine also offers lessons from the international community on how to move forward to protect both people suffering in war and those on the front lines of health care in conflict-ridden places around the world. 

Five reasons why combatants justify attacks 

Rubenstein has created a framework of five reasons why combatants justified attacks on healthcare, namely: to prevent enemies from being treated and returning to fight; to undermine support for rebelling forces; for tactical advantage of taking over a hospital or health centre; refusing to distinguish between military and civilians; and to exploit distrust in government. 

The sources of restraint that can ameliorate or prevent harm to health workers include leadership, domestic or international pressure and accountability, Rubenstein added. 

However, while UN Security Council Resolution 2286, passed in 2016, was one such source of restraint, condemning violence and threats against the wounded and sick, against medical and humanitarian personnel exclusively engaged in medical duties, and against healthcare resources. But the attacks have only increased since.    

More than 700 healthcare workers and patients have died, and more than 2,000 have been injured in attacks on health facilities across 17 emergency-affected countries and fragile settings since December 2017, according to a WHO report released in August. 

Rubenstein called on the global health community to draw its attention towards this pressing issue that seeps into other sectors of health. 

“We need to go beyond the humanitarian, human rights community to address the problem. We talk about the need to develop health systems and universal healthcare – both of those are threatened when health systems are destroyed.” 

More than accountability needed 

Beyond holding the right people accountable for these attacks, there is a need to create lasting change and diminish the violence by engaging with both government and civil society. 

“We often see [violence against healthcare] as merely a problem of accountability, as a collection of outrageous incidents that have to be met with international condemnation and criminal prosecution, if possible,” said Macief Polkowski, International Committee of the Red Cross (ICRC). 

But Polkowski notes that “the arsenal of responses we have at our disposal is far greater.”

“A lot can be done in terms of technical responses, advocacy – these can have practical and concrete effects in terms of diminishing some of these attacks.” 

These “untapped avenues” include engaging with Ministries of Health at the national level to working with professional medical associations. But these efforts require global solidarity and support from both parties.

“[Ministries of Health and medical associations] can take the next step of urging policy changes at the domestic level,” said Rubenstein.

This includes changing counterterrorism laws, demanding militaries adjust their rules of operating in the field, and making sure the voices of those in healthcare in conflict settings are heard. 

Local healthcare workers bear brunt of attacks

Shifting the focus away from the humanitarian workers of high-income countries, whose actions and stories often take center stage, Perilous Medicine instead highlights the individual stories of local healthcare workers.

“Healthcare workers that come from abroad, who come into these conflict settings, are often glorified, or treated as heroic. Whereas actually, the local healthcare workers are the ones who bear the brunt of such attacks on health care in their local communities, on their healthcare facilities, day in and day out,” said Aula Abbara of Imperial College and Chair of Syria Public Health Network. 

Abbara notes how tremendously important it is to talk to the healthcare workers directly involved in the line of conflict, as Rubenstein had done in his book.

“We can all state that more than 900 healthcare workers have been killed directly during the conflict, but every single one of those [who died] has a story.” 

Moderator Tammam Aloudat echoed Abbara’s sentiments about Perilous Medicine: “The genuine way of delivering stories in this work, the ability for us to actually see people rather than statistics, to talk about something that hurts rather than something that gets conceptualized as an academic exercise is one of great significance.” 

Image Credits: International Committee of the Red Cross, GHC.